Pay for Nursing Home Care with Medicare

By Doug Callahan

pay for nursing homeHow will you pay for nursing home care?  In certain situations, Medicare will cover the costs of your nursing home stay, as long as you are eligible. The best resource for getting Medicare to pay for nursing home care is the Nursing Home Compare page on the Medicare website. It’s an online tool that allows you to search and compare all the nursing facilities that are certified by Medicare.

The nursing home quality information reported in Nursing Home Compare comes from two resources:

  • The Online Survey, Certification, and Reporting (OSCAR) Database. State survey agencies collect and report this information to CMS. Data are gathered two ways: by State surveyors during on-site evaluations performed at least once during a 9-15-month period, and through reports (reviewed by the surveyors, but not formally audited for accuracy) produced by the nursing homes themselves. The States update OSCAR data as surveys are completed.
  • The Long-Term Care Minimum Data Set (MDS) Repository – For this database, nursing homes provide to CMS information on each resident’s functional capabilities and medical needs. State surveyors also use this information. The MDS repository is updated quarterly. MDS refers to a data set comprised of core elements and common definitions regarding care provided to residents of nursing homes. The MDS includes standard demographic data for identification such as resident name, birth date, etc. and also contains data elements that describe the resident’s health status in areas such as customary routines, cognitive patterns, and disease diagnoses. All facilities certified to participate in Medicare and/or Medicaid are required by law to encode and transmit the information contained in the MDS to the State (survey agency). The data is collected using a resident assessment instrument designated by CMS, currently MDS 2.0. The State is subsequently required to transmit the data to CMS using the same standard record layouts and data dictionaries. This information is collected and used to ensure that nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS.

So if you want to get Medicare to pick up the tab, here’s how you submit a claim. If you are in the Original Medicare Plan, providers (eg: hospitals, skilled nursing facilities, home health agencies, physicians, pharmacies, and suppliers) that are enrolled in the Medicare program are required by law to file Medicare claims for covered services or supplies you receive from a provider that is enrolled in the Medicare program. You should not need to file any Medicare claims.

Important: Ask the pharmacy or supplier if it is enrolled in the Medicare Program. If you go to a pharmacy or supplier that is not enrolled, Medicare will not pay. You will be responsible for paying the entire bill for any drugs or supplies. Medicare claims must be filed within one full calendar year following the year in which the services were provided. For example, if you see your physician on March 22, 2009, the Medicare claim for that visit must be filed by December 31, 2010. Note: This information on filing a Medicare claim only applies if you are in the Original Medicare Plan. If you get your Medicare health care through a managed care plan (like an HMO) or a Private Fee-for-Service Plan, Medicare claims are not filed. Medicare pays these private insurance companies a set amount every month. Therefore, they do not need to file Medicare claims. Information about when and how to file a Medicare claim.

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